Clinical audit has a history stretching back to the work of Florence Nightingale. On arrival at the medical barracks hospital in Scutari in 1854, Florence was appalled by the unsanitary conditions and high mortality rates among injured or ill soldiers. She and her team of 38 nurses applied strict sanitary routines and standards of hygiene to the hospital and equipment, and with Florence's gift with mathematics and statistics, kept meticulous records of the mortality rates among the hospital patients. Following this change the mortality rates fell from 40% to 2%, and were instrumental in overcoming the resistance of the British doctors and officers to Florence's procedures. Her methodical approach, as well as the emphasis on uniformity and comparability of the results of health care, is recognised as one of the earliest programs of outcomes management.
The National Institute for Clinical Excellence has defined audit as: 'A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria. Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery.' (National Institute for Clinical Excellence, 2002 p.10).
In a more recent Cochrane Review on audit and feedback the authors tightened the definition to: 'The provision of any summary of clinical performance over a specified period of time. The summary may include data on processes of care (e.g. number of diagnostic tests ordered), clinical endpoints (e.g. blood pressure readings), and clinical practice recommendations (proportion of patients managed in line with a recommendation).' (Jamtvedt et al. 2006 p.2)
Jamtvedt et al. (2006) concluded that audit and feedback can be effective in improving professional practice, but the effects can be small. These findings are in line with previous evidence about the value of audit and feedback in changing clinician behaviour. The QASC trialists suggest it could be used in conjunction with the FeSS Intervention package as a means of establishing baseline practices for fever, hyperglycaemia and swallowing management.
The QASC medical record audit was undertaken to ascertain management practices for fever, hyperglycaemia and swallowing management for patients in NSW stroke units prior to, and after, implementation of the FeSS intervention. We developed an audit tool for this purpose which we have modified for use by clinicians.
The QASC Fever, Sugar and Swallowing (FeSS) Medical Record Audit Manual includes the modified medical record audit tool, instructions for use and a data dictionary.